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Both the accompanying editorial (1) and the discussion of the findings of Levy and colleagues (2) provide multiple possible explanations to elucidate the association between intensivists' care and mortality. Project IMPACT may not capture other organizational aspects of the various ICU models and health care systems or hospitals studied that can influence outcome (3).

Regardless, considering the experience of working solely in the ICU, hospital mortality is an important outcome parameter for some ICU patients, but this is not true for all ICU patients. Taken to its logical extreme, 0% mortality by this analysis under any staffing model would represent the highest-performing ICU. Although many would like to believe otherwise, medical intervention in patients who are going to die prolongs suffering, and this effect may be greatest in the ICU (4, 5). Medical intervention in these patients also adds cost to a health care system that is already floundering under the weight of 40 million uninsured U.S. citizens, many of whom cannot receive basic health care that would clearly improve the quality of their lives. Recognizing that patients can and will die at the end of their lives and facilitating this process with a minimum of suffering for both patients and families, while minimizing the cost to the health care system, is far more important than discharge from the hospital alive. The prolonged suffering and costs incumbent on some ICU survivors, many of whom never regain health or independent function or return home, could be mitigated by focusing on more important goals for patients and our health care system than hospital mortality (6).